August 10, 2007

The Case for Single Payer Health Insurance

America’s health care system is imploding. Despite the fact that America devotes more of its GDP to health care than any other developed country, the real outcome for a significant portion of our country is miserable. And despite all the initiatives that claimed to fix the problem, the problem is getting worse. In 1992, forty million Americans were uninsured. Today, after 15 years of depending on the market to fix the problem with HMOs and PPOs and Medical Savings Accounts, more of our GDP is devoted to health care, more than 46 million Americans have no health care coverage during the year, and health outcomes for Americans are poorer than every other developed country.

Worse yet, our approach for paying for health care is undermining the economic health of the country for both businesses and for individuals.

When businesses in other countries compete for work, they are not on the hook for health insurance for their employees. Today the Detroit car companies are competing on a non-level playing field with Toyota or Volvo, because they not only have to provide health care for their current workforce but also their retired workforce. With health care costs rising at double digits every year, this expense is beginning to break the bank. And it is not going to get better until our companies are playing in the same league as the other guys. The end result is fewer jobs with affordable health care coverage.

For individuals, the situation is even bleaker. One of the main ways someone gets into severe economic stress is by being under-insured or by having no insurance when someone in the family gets really sick. Americans who have health problems can find themselves slipping into bankruptcy and poverty without any safety net. And our current system of insurance has been working overtime to deny people care, rather than to cover those who are sick. No wonder a record number of Americans (68%) believe would be better to provide everyone coverage even if it means higher taxes.

Business has come to understand the problem. Today, many business leaders are calling for the government to fix the health care crisis we are experiencing. This is in stark contrast to how the business community responded during the Clinton health care initiative. Back then, the conservative movement realized that if the Clinton health care initiative passed the conservative goal of always choosing market-based programs rather than government programs would be hurt. Conservatives came out heavily against the Clinton initiative (emphasis mine).

Conservatives, led by Newt Gingrich, Bill Kristol, and the National Federation of Independent Businesses—an interest group for small and medium-sized businesses, with a unwaveringly conservative line—recognized the political threat that universal health care posed. In a now-famous strategy memo, Kristol warned that Republicans had to kill, rather than amend, the Clinton proposal. Its success, he warned, would “re-legitimize middle-class dependence for ‘security’ on government spending and regulation,” and “revive ... the Democrats, as the generous protector of middle-class interests.” Kristol and his allies succeeded in convincing big business that their long-term interests couldn’t brook a Democratic resurgence. The change was decisive. The business community mobilized against the Clinton plan, spending $17 million on advertising, and helping to ensure its defeat.

So what changed since then when the worst thing imaginable for business would be letting government regulate health care? Well, for one thing, the world changed and American companies found that they can no longer count on HMOs or PPOs or Medical Savings accounts to rein in costs. And as the costs of caring for the uninsured has been pushed off onto the few remaining public hospitals, their financial wellbeing as well as the soundness of the Medical/Medicare systems are being undermined to the point of collapse. The inherent problem of a patchwork system with minimal regulation has just gotten worse in the years since the last attempt to reform the system.

Now that businesses agree something must be done and 68% of Americans believe it is more important to provide healthcare coverage for everyone than it is to keep taxes down, what should be considered going forward?

One major reason Americans spend so much money on healthcare is because we pay so much in overhead -- 25% of each dollar spent on health care goes for overhead. In fact, the American health care system spends over $1000 per capita -- more than 3 times more than what the Canadians spend on their system. If we saved the excess overhead cost, we could afford to cover health care for all Americans.

The last time our country discussed fixing the health care mess in the early 90s, one of the biggest disappointments for many progressives was that single payer (where the government replaces the insurance companies in paying for care – like they already do with Medicare) was “off the table” from the very beginning. Opponents claimed that Americans would never accept a government managed system.

Why such an objection to single payer? The biggest objection comes from the health care insurance industry who currently are doing exceptionally well in enriching their CEOs and employing numerous gate keepers whose job is to pre-authorize, pay for, or deny care while making a tidy profit. The second objection comes from the business community as they are ideologically predisposed to believe that only market-based solutions are legitimate. The third objection comes from American public who has also been conditioned to disdain government solutions both by the decades long right wing campaign to convince Americans that free markets are best and that government is the problem. (Although, bad corrupt conservative governance where the free market is allowed to prey on Americans is tarnishing that idea.)

Universal health care is particularly unsuited for a market-based approach because people are unable to do a lot of comparison shopping when they are sick and the overwhelming need for health care is when someone is sick, not when they are well. Furthermore, most believe that what level of care they get should not be based solely on their ability to pay or who they work for. Creating artificial markets to provide the illusion of choice has proven to be an unrealistic method for achieving the goal of reasonable and affordable health care for our country. In fact, experience throughout the world shows that a government managed program will provide the best value for our money, both in expense and in quality.

Promoting and enacting single payer health care would provide additional, not insubstantial benefits.

• Americans could once again see that government can be trusted to do something right and something that benefits everyone. This could also begin to restore a level of faith in our constitutional democracy and our ability to work together for a common purpose.
• If health care is no longer provided by one’s job, Americans would no longer have to worry about switching jobs. This could help restore some balance on the employee side of the corporation-employee relationship.
• Americans would no longer have to worry about losing their house or going into bankruptcy when someone in the family got sick if everyone was covered.
• If everyone pays into the same pool, the amount each person pays will be much smaller than if we are all forced to purchase our own insurance with all its commensurate overhead from advertising different plans, paying the outrageous CEO bills, and the bureaucratic mess that doctors and hospitals face in having multiple companies to deal with. With single payer we’ll get far more for less.
• We can build in more transparency into the system because as a public service, the money spent would be overseen by congress and available for all to see.
• We could actually have less regulation and less government interference into our lives.

The current proposals that assume we keep the current patchwork of insurance companies are heavily weighted to building a regulatory system around individuals who will be mandated to purchase insurance (lots and lots of paperwork) and who must be punished if they don’t. Insurance companies will have to be heavily regulated to provide insurance to even the very sick. The end result is more regulation on both businesses and individuals. If insurance companies were cut out of the loop, these regulations would not be needed. All that would be needed is our current tax system collecting our contributions to providing health care for all and expanding our Medicare system to pay for everyone and not just the elderly.

Today, we have a unique opportunity and challenge to do something that will help our entire country be a better place for ourselves and our children. However, if we do not get a chance to argue for single payer, we will be creating yet another Rube Goldberg scheme that works better for corporations than the people while draining away our resources.

[Ed: This was another of my articles written for the Vox Populi Nebraska eZine first published in the June 2007 issue.]

I am an RN who works in a Pediatric ICU, so I see first hand the internal workings of our healthcare system. I work as what is known as a traveling nurse. I work in a location for 13 weeks and then move on to a new location, so I also have experience in more than one area of the country as well as different types of hospitals. I have worked at Duke University and also at the county hospital in Phoenix, AZ. Currently, I work at a hospital just outside Washington, DC. Throughout all these experiences, I have gained pretty strong opinions about what is wrong with the system and what it will take to fix it.

First, what I believe to be wrong with the system. In a nutshell: insurance companies, including government programs. Actually, the medicare/medicaid system is probably the biggest offender here. Every hospital I've ever worked at has had to have a number of people on staff whose full-time job it was to "deal with" insurance issues. I am not referring to the accounting and billing people, these are clinical people (nurses, social workers, etc), who spend their entire day talking to insurance companies about why a patient is still in the hospital, why they're still in ICU, etc. We have insurance adjusters picking apart the patients medical condition and attempting to micro-manage their medical care. On a daily basis, the nurses and physicians involved in the patients care are asked to explain and justify why we're doing what we're doing. I understand the need for accountability, however, when physicians are spending a couple of hours everyday justifying their actions to an insurance adjuster, how are they compensated for this time? Further, how can a nurse provide appropriate care when they know that every action is going to be torn apart for billing purposes? People often wonder why a visit to the doctor costs hundreds of dollars yet they only see the doctor for 5-10 minutes. Because that 5-10 minute visit results in 1-2 hours of additional work for the doctor, the nurses and the office staff. Some of this time is due to legal paperwork having to do with licensing requirements in the sense of "we may need to defend a complaint over this visit to keep my license". Even greater is making sure paperwork is in order enough to withstand being torn apart by an attorney in a malpractice suit, justified or not. I have experienced this same problem in my own family. When I made the decision to step down from a staff position as a nurse and begin to travel, it resulted in a change in employer, hence a change in insurance. My 3 year old son is on a couple of different medications for severe allergies. We were unable to keep him on his established medicines because the insurance would not pay for one until another, cheaper, alternative had been tried. Of course, we had already done this previously, but this documentation wasn't good enough. He had to spend 3 months in agony 'trying' this other medication because the insurance would not pay for the one that we had already established worked for him. In speaking with the insurance company myself, I asked the adjuster I was speaking to (who had the power to approve the correct medication) what type of college degree she held. I was shocked to learn that she had no degree at all. I have since asked this question anytime I have had to deal with an insurance company professionally and found that commonly, the people at insurance companies deciding whether to approve or deny coverage either have no degree at all or have a degree in business or accounting. In my opinion, these people are making medical decisions with no medical training whatsoever. My question regarding insurance companies is this: Why should someone with no medical training or background at all decide what medical care someone should receive? We have people with no more than a high school education second guessing medical specialists in their care of their patients. Does this make any sense at all? I have witnessed this and can tell many more stories in great detail if you would be interested in listening.

I work in an ICU where split-second life or death decisions are made. i.e. the patient is dying and we must save them...do something in the next 15 seconds or they are dead. If you have ever watched an episode of ER when they are scrambling to save someone and doing many things very quickly, remember that all those actions must be documented to defend against an insurance company’s examination days later, calmly sitting at a desk somewhere with all the time in the world to sit and think. Worse yet, to defend against a lawsuit up to 10 years later being microscopically examined by attorneys with all the time in the world. I am sure you have seen episodes of different attorney shows where the attorneys are dissecting a physician’s action on the witness stand. Keep in mind the statute of limitations for malpractice suits is 10 years, longer if the patient is a child. They have until they turn 28 to file a suit. We as healthcare professionals always must keep in mind as we do our "charting" that we must write enough information so we can confidently defend our actions 10 or 20 years and hundreds to thousands of patients later. I make a point of remembering my patient’s names while I am caring for them, but I am just not good enough to remember them all by name forever. Even a few months later, I am sorry to say I remember them better by their medical course than by name. Therefore, in addition to changes in how insurance operates, the court system as relates to malpractice must be changed. You do realize that malpractice insurance costs more for physicians than a lot of people make in a year? For physicians that I work with, their malpractice insurance costs up to $100,000/year. This money must come out of their billing rates. Hence another reason why your 5-10 minute visit costs hundreds of dollars. People tend to think of doctors as rich. Nothing could be further from the truth. Yes, they make a good living, but they literally make life and death decisions on a daily basis. Remember, I work in a Pediatric ICU, so if your child were critically ill or injured, how much is it worth to you for the doctors and nurses who save your child's life? Thinking about it from that perspective, how much should they make? And keep in mind, the doctors to make quite a bit more than us nurses. Add to this equation that most of the doctor’s decisions are made based upon information they receive from the nurses and we get into a whole other argument regarding nursing salaries.

I could ramble on more and more about the problems, but it does not fix anything. Solutions are needed and I have a few thoughts in that area as well. You may think I would be in favor of nationalized healthcare. Actually, I think nationalized healthcare would be even worse than what we already have. As I stated earlier, the government programs are the worst offenders when it comes to what I call insurance meddling in medical care. They say no the most often and have no avenue to make a more detailed argument to attempt to prove the necessity of a needed treatment. Talk to anyone, especially someone in the medical field, who has emigrated from Canada and they will tell you how poor the healthcare is in Canada. Sure, everyone is covered and all healthcare is essentially free, but what level of healthcare do they have. I have worked with many nurses from Canada who have stated without reservation that the medical care provided in Canada is vastly inferior to that of the care here. The principle of free enterprise and competition improving the quality of a product applies in healthcare as much as it does anywhere else.

I sincerely feel and believe with all my being that the insurance industry as it exists is the very foundation of the problems in the healthcare system. How to fix that? Somehow create a system whereby decisions on coverage are made based on sound medical grounds, not financial considerations. Perhaps a law requiring physicians in the appropriate specialty making decisions regarding coverage and authorizations without regard to costs. Insurance companies always complain about the high cost of healthcare, yet they are the primary reason for it. Perhaps a standard form whereby the physician can state "this is the patients condition, this is what we need to do", and then get a yes or no without multiple requests for more information. This would result in the physician performing much more efficiently, thus enabling the billing rate to be more reasonable. There are other ways to address this as well.

In combination with this must be some kind of reform of the malpractice laws. There are much too many frivolous lawsuits being filed and making it all the way to trial. There has to be a way to hold attorneys accountable for clogging the system with cases that should not even see the light of day. I have encountered respected attorneys who have medical personnel on their staff who research cases for merit before deciding to even take a case. The burden in medical malpractice is "acceptable medical practice". This perhaps needs a more specific definition. Also, not to put a value on a life, but is "uncle john", who dies at 85 due to complications after surgery really worth $100 million? This seems outrageous to me. The constitution states "a jury of peers" in criminal cases. Should a doctor or nurse in a malpractice case not be afforded the same protection? Perhaps a jury composed of doctors or nurses who actually have the training and experience to judge the actions taken in the case?

I do not claim to have all the answers to this problem, but I do feel I am extremely qualified to pinpoint the causes of the problem. I would be happy to answer any questions and/or discuss further with anyone who is interested in discussing this issue with an open mind. Bottom line is this: show me a government run program in ANY AREA that works, and I may rethink my position somewhat.

Marty G., RN

Posted by: Marty G., RN at August 11, 2007 07:04 AM

Hmm, my father's cousin's serious cancer was treated well. My cousin has had all of her preventive health care and birthing done in Canada. Hell, my tonsil's were removed in Canada.

I prefer Canada, myself. I think doctors are too busy covering their butts here - and there are lots of very incompetent doctors. No thanks. Frankly, my partner and I have decided to carefully consider all options before giving ourselves over to the medical community and the big pharmaceuticals.

From the patient's side of things, I dealt with Medicare on behalf of my disabled husband for a decade, and I found the people quite reasonable. Either they agreed with my point (that nutrients in a can you pour down a feeding tube is not like Ensure-type nutrients in a can, say) and allowed it, or told me my point (that moving 100 miles necessitated changing durable goods suppliers, say) was sensible but that the regulations specified doing X in way Y (with a hint that I should hassle my congressman to get the regs changed).

My dealings with my private insurance company now are not so pleasant.